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UNITED STATES OF AMERICA. 



THE 



MEDICAL EXAMINER'S 



MANUAL. 



D. S V GLONINGEE, M.D. 




1 PHILADELPHIA: 
OLAXTON, REMSEN, AND HAFFELFLNGEE, 
1869. 




mi 






Entered according to Act of Congress, in the year 1S69, by 

CLAXTON, REMSEN, AND HAFFELFIXGER, 

in the Clerk's Office of the District Court of the United States for the 
Eastern District of the State of Pennsylvania. 



COLWNS, TRIXTER. 






Shis Walnm 

IS RESPECTFULLY DEDICATED 

TO 

Hox. HENRY CROCKEE, President 

UNION MUTUAL LIFE INSUEANCE COMPANY, 
BOSTON. 



THE MEDICAL EXAMINEE. 



The success of life insurance companies de- 
pends, principally upon the character of risks 
taken ; the stability of investments upon the 
financial capacities of the officers. A rigid scru- 
tiny into the competency of each class is the 
only guarantee to the policy-holder that his 
money will accrue to the benefit of his or her 
legatees, when the time comes to cancel obliga- 
tions. 

Proficiency in medical diagnosis and strict in- 
tegrity are requisites in the selection of medical 
examiners. 

We lay stress upon diseases of the lungs and 
heart primarily, but we would not give a second- 
ary position to organs as much concerned in the 
vital econonrv. (We illustrate this point by 
referring to the query contained in all applica- 
tions. Has the party had any disease of the 
" 1* 



liver or kidneys, dyspepsia, colic, dysentery, 
hernia, strangury, haemorrhoids, or an}- diseases 
of the abdominal viscera ?) 

Diseases of the lungs and heart are insidious 
in their character, but none the less are others 
in the great catalogue. Many depend upon a 
series of others and are consequent thereto. 
We take another question, " Has the party scro- 
fula, rheumatism, gout, dropsy, or any other 
disease not enumerated hitherto V Xo physician 
vail deny that there is a strong tendency to 
diseases of the heart in acute cases of rheuma- 
tism ; and the intimate relation between these 
two important organs should be fully considered 
in an examination by him. 

Each question of the application is an index 
to the plrysician in his operations. The general 
history of the patient in the first question is the 
entering wedge, and should place him on the 
alert. The person desiring to be insured is 
different from the conscript. The latter pur- 
posely makes his case look worst. The appli- 
cant for insurance can see no flaw in his plrysical 
organization. He is strictly temperate and will 
often be offended at the physician, should he 
presume to lay bare at some unguarded moment 



a constitution unfitted as a safe risk for any Life 
Insurance institution. 

In these fast da} T s the first question as to 
men's habits is as puzzling as medical diagnosis. 
What constitutes an intemperate drinker ? 
That drinking is confined to no special class, we 
quote from Dr. Day's report of inmates of Bing- 
hampton Inebriate Asylum. 

"Out of Xew York and Brooklyn, 10T ; from 
other parts of the State, 83 ; from Massachu- 
setts, 19; from Pennsylvania, 20 ; Virginia, 3 
Ohio, 19 ; Indiana, 6 ; Michigan, 6 ; District of 
Columbia, 3 ; California, 1 ; Louisiana, 1 
Georgia, 2 ; Minnesota, 1 ; Kentucky, 2 ; Mis 
souri, 1 ; England, 9 ; Scotland, 3 ; Ireland, 6 : 
German}^, 1 ; Canada, 3 ; West Indies, 1. Of 
these there were: Clerks, 93; merchants, 82 
manufacturers, 4; clergymen, 3; organists, 2 
druggists, 6 ; bankers, 9 ; dentists, 2 ; farmers 
16; lawyers, 15; physicians, 10; brewers, 2 
telegraph operators, 3 ; civil engineers, 4 ; me- 
chanics, 6 ; printers, 3 ; students, 5 ; editors, 2 ; 
authors, 3 ; of saloon-keepers, hotel proprietors, 
artists, and polishers, 1 each ; and of no regular 
vocation, 28." 

This category shows how the class of men who 
become victims to the fusel-fiend mostly belong 



8 

to walks of life wherein intellect and nerve are 
under constant stress. Even farmers of the more 
cultivated kind are few. But clerks driven to 
exhaustion by overwhelming work ; lawyers 
fuddled with the film of cerebral cobwebs that 
they get to fancy only alcohol can clear away ; 
and writers, too, are plenty. Even physicians 
could not help themselves, and druggists found 
their acquaintance with pharmacopoeia inef- 
fectual. 

On this point insurance companies should 
classify the risks, all things being equal. The 
strictly abstemious man should be marked first 
class, and the gradations should be in propor- 
tion to the indulgences, as seen and known of 
the insured. 

Dr. Day thus ably and exhaustively epitomizes 
the two principal forms of development in which 
the drinking of ardent beverages are manifested : 

The term dipsomania is applied by certain 
writers on diseases of the mind, to a peculiar 
form of insanity. The term is intended to de- 
signate and describe that impulse towards the 
use of intoxicating liquors, w r hich is known to 
arise suddenly in some persons at periods re- 
moved from each other, in contradistinction to 
that craving which is established graduallv 



through the influence of habit, and which con- 
tinues with unbroken and undisturbed regularity. 
This kind of insanity becomes as truly a malady 
as any other form, but the impulse now referred 
to has been regarded as a malady from the be- 
ginning. The daily drinker has deliberately 
cultivated his propensity until it has gained 
complete ascendency over him, and his uncon- 
querable longings were originally the growth of 
that will over which they now hold undisputed 
sway. But the victim of dipsomania, from a 
condition of complete sobriety, is hurried into 
excesses of a most fearful character, with the 
full consciousness of the foul debasement before 
him, which, in his own despite, he is unresistingly 
impelled to encounter. You know the intensity 
of that craving for stimulants which all drink- 
ing men experience after a protracted debauch. 
Such in kind and degree is the craving which 
takes possession of the individual we characte- 
rize as the victim of dipsomania before his lips 
have been polluted, or his system poisoned by 
alcoholic stimulants, and while yet in a state of 
perfect plrysical sobriety. This condition of 
disease is b}^ no means rare. Many such cases 
are reported in the medical journals of France, 
Germany, and England. Men of experience in 



10 

this country have reported similar cases, and 
certainly more than a thousand have come under 
my own observation. There are gentlemen be- 
fore me who have been subject to this insane 
impulse towards intoxicating drinks. I cannot 
say that I am familiar with a case in which this 
impulse has not been at some period of life 
awakened, and perhaps fastened by a moderate 
use of stimulants. I am not entirely certain on 
that point. But I do know of affections of this 
sort where the exciting causes may be either 
some physical uneasiness or some condition of 
mental depression. Those persons who are 
liable to nervous excitement seem to be especially 
predisposed to it. It may, therefore, be con- 
nected with temperament and constitution, and 
in some instances it has seemed to be hereditary. 
The paroxysm has been known to burst forth 
with irresistible violence after a period of irrita- 
tion and anxiety wholly indescribable, and in- 
toxicating fluids of every description are poured 
down with an eagerness bordering on madness, 
till insensibility- ensues. 

The chronic form has often causes more re- 
mote than continuous, under the action of which 
the passion for stimulants amounts to a mania^ 
seemingly irresistible and incurable. These 



11 

causes are either idiopathic, or are induced by 
habits or manner of life. Among these may be 
mentioned a mental constitution unbalanced in 
its moral faculties ; congenital physical weak- 
ness, resulting in a morbid tendency to melan- 
choly ; a weak individuality, and a disposition 
easy, good-natured, and social. The disease is 
frequently induced by misfortune, which darkens 
and embitters life ; or by contrary successes, 
which unduly excite the mind. The miserable, 
the irresolute, the listless, the unoccupied, and 
those too much burdened with care or labor, are 
the subjects of it. 

While the agency of alcohol in large quanti- 
ties is admitted to be very great in the produc- 
tion of gastric diseases, it is a too general 
opinion that the regular, habitual use of it in 
small quantities acts favorably by the gentle 
stimulation of the digestive functions. The 
grounds of entertaining this opinion are fallaci- 
ous ; and I agree with Dr. Hodgkins (Copeland, 
p. 784) in saying that u the habitual employment 
of such stimuli must be injurious, by blunting 
the sensibility of the stomach to those articles 
which are really nutritious, as well as by con- 
taminating, by the admixture of a deleterious 



12 

principle, the nutritious juices which the absorb- 
ant vessels have to imbibe." 

No one will write himself down an inebriate, 
yet there must be a beginning somewhere, and 
the medical man is asked the question direct. 
Does anything in the party's figure, general 
appearance, manners, or conversation indicate ill 
health, feeble constitution, irregular or intem- 
perate habits ? 

1. Of what height ? Weight? Girth ? and 
Temperament ? 

We produce a standard of weights and height 
as matter for reference. It will appear as a 
guide in question 1st in Medical Examiner's 
Certificate. 



13 



Table of the Proper Proportion of tie height of 
Individuals to their Weight. 



EIGHT. 




Ft. 


In. 


5 


1 


5 


2 


5 


3 


5 


4 


5 


5 


5 


6 


5 


7 


5 


8 


5 


9 


5 


10 


5 


11 


6 


00 



weig:it. 
Lbs. 
120 
125 
130 
135 
140 
143 
145 
148 
155 
1(10 
165 
170 



Much stress is laid by some companies on 
conformity with such tabular statements. Risks 
are often held in the hands of the company for 
further consultation, wherein some peculiar de- 
viation is found not altogether up to standard ! 
No greater mistake can be conceived of than 
this. It virtually binds the examiner's hands 
and feet. His judgment should certainly have 
some consideration in every case before him. 
There are certain families which are long-lived — 
running back in generations — where great devia- 
tions are observable, some of excessive weight, 
2 



14 

others deficient^ small — then, the above standard 
taken would be counted altogether abnormal. Yet 
the}^ live out the full expectation nevertheless. 

We have in medical examinations a little more 
to look to than power of endurance. The scru- 
tiny of the plrysician is much more comprehen- 
sive. It is not a mere question of excess or 
defect of bon} T structure, but general physical 
development, which takes in every organ and 
function. 

A man 5 feet 2 inches in height may go 
through a campaign with all its fatigues much 
better than one taller, yet there may be equally 
as much vital capacity in the latter. The ques- 
tion for the physician to determine is rather this, 
(in an insurance risk) does the chest formation 
present a sufficiency in expansion and inspira- 
tion to insure a sound pair of lungs ? A small 
.man may measure infinitely more around the 
thorax, and yet be an abnormit}", and so other- 
wise. 

It were better to lay less stress upon statistics 
and take such as mere stepping-stones in the 
furtherance of a more rigid diagnosis. We con- 
ceive it to be an invitation on the part of the 
company to the examiner to give minute atten- 
tion to ".development" and nothing further. 



15 

Next comes the question of " girth." Measuring 
the chest across the nipples with the arms down. 

The applicant must be inspected not with that 
rigidity of an army inspector, yet insomuch as 
to be able to discover whether there be any de- 
formities or u gibbosities" which might impair 
the lung or heart structure. Thus far and no 
farther is the question of value — all other inten- 
tions are mere quicksands, and will mislead and 
clestroj- nine-tenths of all risks offered. 

Temperament, however, is a more important 
feature. It mirrors the man. Is he plethoric ? 
we have a guide which will bring us at once to 
the scrutiny of his bloodvessel sj^stem. And we 
will weigh well Question 3. Has there been any 
insanity, apoplexy, or an}^ predisposition ? And 
so in each of the four temperaments. Leading 
up by gradation into the very heart and pith of 
every species of disease, the nervous, the glan- 
dular, the secretory, and bloodvessel systems of 
the human economy. 

The question — how much of expansion, which, 
as a general thing, should be three inches, is a 
very deceptive guide to the examiner. 

The medical examiner should inspect the chest 
in the infra-clavicular region especially, whether 
depressed or rounded in the contour of the tho- 
rax. The muscular development, whether the 



16 

muscles are rigid and respond well to volition 
or no ; whether they are flabby and there is a 
similarity of development symmetrically. Much 
may be learned by these rninutia?, and taking* 
like ages as a criterion, in proportion as risks 
come up to a good physical development, just so 
near will the medical examiner be right in his 
affirmative or negative answer. 

Question 3d on Application. Name in full, 
occupation and residence of person whose life is 
to be insured. Seemingly very unimportant, 
but upon more close scrutiny most valuable in 
answering Question 11 of Medical Certificate. 
Question 11 has reference to expectation of life. 
Expectation is based upon the Carlisle Table, 
which, for rates of insurance, will answer all pur- 
poses, but as a mortuary guide is very unsafe 
and unsatisfactory. It reduces intelligent opin- 
ions of the medical man to mere guess-work. 
We conceive that the question of occupation has 
far more to do with the value of the risk pro- 
posed and the lease of life, and should take pre- 
cedence in the medical man's " prognosis." 

We give a very careful compilation of statis- 
tics prepared by a French physiologist, Mons. 
Lombard. In comparison we give the Carlisle 
Table, leaving medical men to draw their own 
conclusions. 



17 



ring 


the Expectation of 


Life at every Age 


according to the Observations made at Carlisle. 


Age. Expect. Age. ExrECT. 


10 . ... 43. SI 40 . . 27.61 


11 






. 4S.04 41 






. 26.97 


12 






. 47.27 42 






. 26.34 


13 






46.51 43 






25 71 


14 






45.75 44 






. 25 09 


15 






. 45.00 45 






. 25.46 


16 






44.27 46 






. 23. S2 


17 






43.57 47 






23.17 


IS 






42.87 48 






22.50 


19 






42.17 49 






21.18 


20 






41.16 50 






. 21.11 


21 






40.75 51 






20.39 


22 






40.04 52 






19.68 


23 






39.31 53 






18.67 


24 






3S.59 54 






18.28 


25 . 






37.86 55 . 






17.53 


26 






37.14 56 . 






16.89 


27 






36.41 57 






16.21 


2S . 






35.69 58 






15.55 


29 






35.00 59 






. 14.92 


30 






34.34 60 






14.34 


31 . 






33.68 61 . 






13.82 


32 






33.03 62 






13.31 


33 . 






32.68 63 . 






12.71 


34 






31.78 64 






12.30 


35 






31.00 65 . 






11.79 


36 






30.32 66 . 






11.17 


37 . 






29.64 67 . 






10.75 


38 






28.95 OS . 






10.23 


39 






28.28 69 . 






9.70 



18 



Lombard's Table, Rate of Mortality in Occupation*. 



Occupation. 








Age 


Stone Cutter. 34 


Miller, .... 








42 


Painter, 








44 


Joiner, .... 








49 


Butcher, 








53 


Lawyer, 








51 


Surgeon, 








54 


Mason, ..... 








25 


Gardener, .... 








60 


Merchant, .... 








62 


Clergyman, . 








63 


Magistrate, . 








69 


Poet, .... 








55£ 


Statesman, 








61 


Military Commander, . 








59 


Philosopher, .... 






• 


59 


Musician, 








63 


Sculptor, 








63 



The Carlisle Table is a fixed standard; the 
Lombard Scale, sliding. Is not this more prac- 
tical ? Exposure weighed against the more re- 
lining influences of societ}'. We take the mor- 
tality of the mason, rated at twenty-five, and 
compare it with the statesman or either of the 
others, and what a material difference in the 
record ! The various improvements in ventila- 
tion, sewerage, general hygienic principles, daily 



19 

becoming more and more common, and the 
thorough, sj'stem of public schools educating 
people up to higher standards of health, must 
tell with great power upon the mortuary cycle. 
It tells now. What will it be as society escapes 
from the slough of old prejudices and sees from 
an elevated educational stand-point ? 

We hold that the medical examiner must only 
give heed to the question in so far as his judg- 
ment is based upon correct principles of " hy- 
giene" and only as a guide to farther investiga- 
tions. 

Dr. Guy says, in his work on statistics, " If 
the sanitary condition of the entire country could 
be raised to the condition of the most healthy 
countries, there would be an annual saving of 
about one-seventh of the number of deaths." 
The mortality of cities is owing in a measure to 
crowded dwellings, personal uncleanliness, the 
concentration of unhealthy emanations from nar- 
row streets, without fresh air, water, or sewers. 
Locality and occupation are so blended together 
in the risk, that even in the same classification 
of occupation the grade of the answer must de- 
pend one upon the other. No medical man can 
safely take a risk until the surroundings are well 



20 

canvassed, and these should have a great influ- 
ence on his decision. 

In Question 3d of Examination and Questions 
8 and 11 of Application we have brought to our 
notice what are Hereditary Diseases : as a class, 
they are whatever is transmissible, or constitu- 
tional in character, frojn generation to genera- 
tion. In this class we would mark consumption, 
scrofula, some nervous diseases, chorea, epilepsy, 
cutaneous diseases and syphilitic ; and all such 
as produce themselves sui generis. 

The question as to family history is correlative 
and only auxiliary to a future physical explora- 
tion. It is a known fact that consumption or 
any of the hereditary diseases, do not always 
exhibit themselves in the succeeding generation. 
The taint may lie dormant and yet be entailed 
in a future generation ; actually skipping over 
one line of lives and redoubling its violence in 
the third generation. Thus we account for Ques- 
tion 10. Application; " Please state whether 
paternal or maternal grandparents, uncles or 
aunts of the party have died or been afflicted 
with consumption, insanity, or any hereditary 
disease?' 7 

Chances of Death by Different Diseases. — Tak- 
ing the English population in the aggregate the 



21 

chance that among the various forms of death 
the fate which a human being must encounter 
will be accidental or from injury wilfully in- 
flicted, is nearly as one to 29. The chance that 
death will be by zymotic disease is as one to 6 ; 
and the chance that it will be by consumption is 
nearly as one to 9 ; but, of course, the risk is 
increased, to some, and, therefore, lessened to 
others, according to occupation, sex, age, and 
other circumstances. The following results, 
showing the proportional number of deaths in 
England in 1867 from each cause to 1,000,000 
deaths from all causes, arranged in the order of 
their fatalit}^, w T ill enable the chances of death 
by different diseases to be determined in the 
above . manner : From consumption, 118,003; 
bronchitis, 86,554 ; atrophy and debility, 69,284 ; 
old age, 61,414 ; convulsions, 56,294 ; heart dis- 
ease, 46,499 ; pneumonia, 45,275 ; diarrhoea, 
42,559 ; typhus, 36,150 ; scarlatina, 26,310 ; hoop- 
ing-cough, 25,454; paralysis, 2^,175 ; apoplexy, 
22,309; premature birth, 19,272; cancer, 18,320 ; 
drops} r , 15,112; hydrocephalus, 15,095; tabes 
mesenterica, 14,754; fracture and contusions 
(accident), 14,141; measles, 14,124; brain dis- 
ease, 12,158; liver disease, 11,859; lung disease, 
10,278; croup, 9405; teeth, 9219; cephalitis, 



22 

9047 ; asthma, 8035 ; sudden death cause unas- 
certained, 7516; stomach disease, 6320; scrofula, 
6299; kidney disease, 6260; enteritis, 6127; 
drowning (accident), 5737 ; burns and scalds 
(accident), 5574; diphtheria, 5574; smallpox, 
5388; childbirth, 5029 ; epilepsy, 4957 ; rheuma- 
tism, 4837 ; nephria, 4723 ; syphilis, 3641 ; joint 
disease, 3584 ; peritonitis, 3368 ; jaundice, 3201 
eiysipelas, 3109 ; want of breast milk, 3080 ; suf- 
focation (accident), 2899 ; mortification, 2849 
hepatitis, 2828 ; laryngitis, 2755 ; ileus, 2528 
thrush, 2493 ; accident not specified, 2393 ; ute- 
rus disease, 2291 ; metria, 2285 ; dysentery, 2062 
ulceration of intestines, 1990 ; hernia, 1987 
cholera, 1977 ; pleurisy, 1854 ; gastritis, 1591 
ascites, 1552 ; diabetes, 1458 ; insanity, 1372 
influenza, 1301 ; pericarditis, 1269 ; malforma 
tions, 1081; aneurism, 1078 ; hanging (suicide) 
1046 ; cj^anosis, 1031 ; purpura and scurvy, 1010 
ulcer, 950 ; nephritis, 948 ; phlegmon, 922 ; mur- 
der and manslaughter, 840 ; spina bifida, 832 
cj T stitis, 817 ; gout, 808 ; intemperance, 802 ; de- 
lirium tremens, 791 ; skin, 776 ; violent deaths 
not specified, 641 ; introsusception, 635 ; poison 
(accident), 602 ; stricture of intestines, 596 ; cut 
or stab (suicide), 575; ovarian dropsy, 530 ; car- 
buncle, 504 ; drowning (suicide), 489 ; stone, 431 ; 



23 

quinsy, 431 ; stricture of urethra, 422 ; noma. 373 ; 
worms, 309 ; suicide (means not stated), 300 ; 
poison (suicide), 289 ; gunshot (accident), 266 ; 
ague, 259 ; pavamenia, 247 ; privation, 234 ; is- 
churia, 227 ; zymotic diseases not specified, 225; 
cut or stab (accident), 221 ; fistula, 214 ; spleen, 
199; remittent fever, 184; arthritis, 161 ; gun- 
shot (suicide), 122 ; chorea, 107 ; pancreas dis- 
ease, 39 ; hanging (execution), 24; hydrophobia, 
21 ; glanders, 9. Out of every 1000 deaths, 195 
were caused by zymotic diseases, 192 by consti- 
tutional diseases, 402 by local diseases, 167 by 
developmental diseases, and 36 by accidental 
and other violence — N. T. Underivriter. 

Question 4. Has the party had local or gene- 
ral paralysis, apoplexy, epileps}% or other dis- 
eases having their seat in the brain or nervous 
system, or any predisposition thereto ? We 
have in measure met these points in former arti- 
cles on hereditary diseases. Much will depend 
upon general inspection in such cases, and the 
study of temperament and the dynamic forces 
of the system, as displaj^ed in muscles control- 
ling locomotion and speech. These will tell as 
to the peculiar tendencies of the applicant. In 
females man}' of these diseases are hysterical, 
and on the removal of the cause the disease sub- 



24 

sides. As we find a difference exists in the sex; 
and while a negative answer may be given to the 
application, in case of a male, in the female it 
should be suspended or postponed, not abso- 
lutely rejected. Where there is vertigo, with 
constant headaches, the subject having a short 
neck, with the head lying low between the 
shoulders ; and where there is a general plethora, 
with a sluggish pulse, full and bounding under 
the fingers, with a prior short family history on 
the part of both parents, one or other dying 
of apoplexy, the application may be at once 
rejected. 

The whole cerebro-spinal system is the subject 
of study, and any deviations from normal stand- 
ard should be carefully noted. Tenderness along 
the spinal column, or an}^ want of response in 
the cranial nerves, whether of the eye, ear, or 
gustatory apparatus, should be a caution to the 
examiner, and he will proceed as if there were 
breakers ahead. Should the nervous system be 
involved sympathetically (and much in indi- 
viduals depends upon " anemia"), the physician 
might suggest a toning of the sj^stem by chaly- 
beates, etc., and postpone the examination until 
an improvement may be observable. This is 
due to both parties. If, however, on a second 



25 

examination, evidences of a dyscrasia still exist, 
it would be prudent not to take the risk. The 
consequences of prolonged anemia lead to prac- 
tical disturbances too serious to assume the 
responsibilities. When paralysis pictonum exists 
and is evidenced by the blue line about the gums 
(in painters a disease amenable to treatment), a 
proper course of regimen being suggested after a 
sufficient lapse of time, the risk may be accepted, 
evidence existing that the lead poison has been 
eradicated. Of course this would come under a 
different classification as to character of risks 
and corresponding rates. Should the medical 
examiner hesitate, it were well for him to submit 
the case with full details to the general office for 
final adjudication. Delirium tremens and abuse 
of opium and tobacco are grave subjects for the 
medical examiner. 

The Effects of Tobacco on Boys. — Dr. Decasine, 
in the course of investigations on the influence 
of tobacco on the circulation, has been struck with 
the number of boys, aged from nine to fifteen, 
who smoke, and has been led to inquire into 
the connection of this habit with impairment of 
the general health. He has observed thirty-eight 
bo3 r s, aged from nine to fifteen, who smoked 
more or less. Of these, distinct symptoms were 
3 



26 

present in twenty-seven. In twenty-two there 
were various disorders of the circulation — bruit 
de soufflet in the neck, palpitation, disorders of 
digestion, slowness of intellect, and a more or 
less marked taste for strong drinks. In three 
the pulse was intermittent. 

In eight there was found on examination more 
or less marked diminution of the red corpuscles ; 
in twelve there was rather frequent epistaxis; 
ten had disturbed sleep; and four had slight 
ulcerations of the mucous membranes of the 
mouth, which disappeared on ceasing from the 
use of tobacco for some days. In children who 
were very well nourished, the disorder was, in 
general, less marked. As to the ages, eight of 
the boys were from nine to twelve years old; 
nineteen from twelve to fifteen. The duration 
of the habit of smoking was, in eleven, from six 
months to a year, and in sixteen more than two 
years. The ordinary treatment of anaemia in 
general produced no effect as long as the smoking 
was continued ; but when this was desisted from, 
health was soon perfectly restored, if there was 
no organic disease. — British Medical Journal. 

The general appearance of the individual must 
be the guide in his final decision. Where an in- 
dividual has had one attack of mania-a-potu, the 



21 

probability is that the brain and nervous system 
have received so great an injury as to predicate 
great trouble in the future. While there are ex- 
ceptional cases and reforms, as a general thing 
these are scarce and far between. It is good 
policy to reject, where the statement of the above 
facts appears or is elicited by examination. The 
same may be said with similar abuses in tobacco 
and other noxious weeds. 

Question 5, of certificate, opens thus : " Has 
the party ever spit blood, or been subject to 
cough, profuse expectoration, difficulty in breath- 
ing, or any other disease of the lungs?" This 
devolves upon the applicant to answer. Informa- 
tion thus gained is introductory to question 6. 
Are the lungs in a perfectly healthy condition ? 
Is the respiration full, gentle, and regular ? 
Does percussion give a normal resonance ? 

This brings us into the field of exploration of 
lung tissue, and here we conceive to be the real 
responsibility of the medical examiner. 

Diseases of the lungs are recognized by certain 
local and constitutional symptoms which take 
hold of the lung life or vital capacity ; the external 
physical signs localize the variations from health 
in the lung tissue. Hence in forming a judg- 
ment of health or disease, we combine both ; 



28 

laying stress upon sounds, while we do not for- 
get " the vital symptoms in cough expectoration, 
analysis of sputa, dilatations of bronchi," &c. &c. 

It requires a general knowledge on the part 
of the examiner, a mere superficial exploration 
will not do ; the medical man must make clean 
work, as he advances. 

First, then, what does a healthy lung reveal? 
Certain unmistakable sounds, the absence of 
which should excite suspicion or alarm. These 
are ascertained by percussion and auscultation. 

Percussion develops clearness or dulness in 
healthy or diseased lung tissue, and circumscribes 
them to particular regions, which for conveni- 
ence' sake have been divided into fixed localities. 
Auscultation gives sounds peculiar to health, in 
contradistinction to those of disease. 

" Sounds of Respiration" are vesicular, pue- 
rile, tubal. Disease modifies these, and we have 
u Rattles," moist or dry, cavernous or otherwise, 
during every act of respiration. Yocal vibra- 
tions, sonorous or sibilant, and friction sounds, 
each conveys a meaning full of import to the 
medical man, favorable or otherwise to the ac- 
ceptance or rejection of the case in hand. Hence 
the importance of having a practised ear, able to 
detect the least deviation in resonance! Espe- 



29 

cialh* where the special functions of the lungs 
are in issue! 

What constitutes a healthy lung, and how 
shall we ascertain the fact by the various appli- 
ances — palpation, percussion, measurement, suc- 
cussion, and auscultation? 

Here we assume the comparative side of the 
question, having already entered into the details 
of height, weight, temperament, locality, and the 
incidents thereto in the development of disease 
or furtherance of health. 

How does the applicant approach the health 
standard? 

In the first place, the bony thoracic cavity 
should be well developed and symmetrical ; the 
expirations and inspirations full, gentle, and 
regular. The play of the lungs should not be 
impeded by false attachments, and the general 
rotundity of the chest should be uniform on each 
side throughout. 

Does the chest expand uniformly and regu- 
larly on both sides ? To test uniformity and 
regularity, we give Hutchinson's Table. 



3* 



30 



RESPIROMETER TABLE—" HUTCHINSON'S." 













From obser- 


Regular pro- 




Height. 






vation. 


gression. 












Cubic inches. 


Cubic inches 


5 ft. 


— 


5 ft 


1 


in. 


174 


174 


5 " 1 in. 


— 


5 " 


2 


" 


177 


182 


5 " 2 " 


— 


5 " 


3 


< i 


189 


190 


5 " 3 " 


— 


5 " 


4 


i i 


193 


198 


5 " 4 " 


— 


5 " 


5 


C ( 


201 


206 


5 " 5 " 


— 


5 " 


6 


" 


214 


214 


5 " 6 " 


— 


5 " 


7 


" 


229 


2*22 


5 " 7 " 


— 


5 " 


8 


i ( 


228 


230 


5 " 8 " 


— 


5 " 


9 


" 


237 


238 


5 " 9 " 


— 


5 " 


10 


a 


246 


216 


5 "10 " 


— 


5 " 


11 


" 


248 


254 


5 "11 " 


__ 


6 " 






259 


262 



To the question, How many inspirations per 
minute, we give the following table as a guide : — 



QUETELET'S TABLE. 



Age. 

At birth, 
5 years, 
15 to 20, 
20 to 24, 
25 to 30, 
30 to. 50, 



Provost and Dumas place the ratio of respira- 
tions to pulsation as 1 to ±. 



IH 


5PIRATION. 




Average. 


Max. 


Min 


44 


70 


23 


26 


32 


— 


20 


24 


16 


18.7 


24 


14 


16 


21 


15 


18.1 


23 


11 



31 

D. C. Hooker, of Boston, says any deviation 
from this relation (1 to 4i) indicates some me- 
chanical or structural impediment to the free 
play of the lungs. 

Where such deviation occurs, the medical ex- 
aminer should pause and seek information from 
the family history. It may tend to discover or 
remind the applicant of some question carelessly 
answered or overlooked by him. 

So much for discoveries by palpation, inspira- 
tion and expiration, and general exterior of lung 
structure. The position we assume is, that in 
all these details it is incumbent upon the medi- 
cal men to be conversant, and to assume that 
each examiner, to do his duty, should give each 
and every point, whether small or great, a care- 
ful supervision. 

It must be borne in mind that in Diseases of 
the Lungs the examiner has to do with "chronic 
cases ;" and evidences deducible from physical 
and vital signs in early stages are not so easy 
of detection as in the acute — phthisis excepted. 

We have to do with relics of prior diseases, 
and it is for the physician to say whether, if there 
be unsoundness, there be sufficient to pronounce 
the risk impaired and unfitted to be accepted. 
To assume that the least departure from health 



32 

is basis for rejection, is too sweeping. The ob- 
jections should be vital. 

In the outstart of an examination, to the ques- 
tion, Had you disease of the lungs ? the appli- 
cant may answer, as he often does, "I have had 
a cold; it was trifling, however, and did not pre- 
clude me from following my business." To be 
satisfied with this alone, the examiner would be 
thrown off his guard. It behooves him to press 
his inquiries with minuteness. "Whether there 
was fever with the cold ? Whether there was 
expectoration, color, and consistence? Whether 
there was pain in any portion of the chest? 
Whether there was loss of voice, &c. ? He 
should look for marks of pustulation or vesica- 
tion in the thorax ; these will indicate the extent 
of the cold ! How, otherwise, will he be able to 
locate the disease understandingly ? 

Cold, or catarrh, is another name for bron- 
chitis. It applies to any grade of inflammation 
of the mucous membrane, from the nostrils down- 
wards to the lung tissue. Percussion reveals 
little; auscultation much. In these cases, u rat- 
tles" have different sounds, at first dry ; as the 
disease advances, moist mingled with dry; the 
respiratory murmur weakened, where diseased in 
smaller vessels, sibilant rattles predominating. 



33 

The natural gradation of respiratory murmur 
in young children (say until three years), the 
respiration is much louder than in the adult, and 
is called "puerile ;" in old persons it is weaker. 
If these respective sounds be misplaced, there is 
evidence of mischief. 

Dry rattles are produced by congestion and 
thickening of mucous membrane; as suppuration 
supervenes the rattles become moist. Where the 
disease involves the large bronchia, the rattle is 
sonorous. 

£911^ Disease of the heart is frequently dis- 
guised in bronchial symptoms. Where cutane- 
ous disease exists and bronchial trouble shows 
itself, the medical examiner, looking for the pre- 
disposition to " metastasis," should guard care- 
fullv the sounds and functions of the heart. 

Irregular distribution of blood in the lungs by 
improper action of valves of the heart, predispos- 
ing to passive congestions, frequently develop 
bronchial and kindred diseases. 

Another important point is the character of 
vocal resonance. 

Pneumonia concerns the parenchymatous 
structure, the inflammation distributing itself 
into the lobe structure. What have been the 
effects of such disintegration ? Percussion will 



reveal differences of sound in the base, and reso- 
nance be increased or diminished in proportion 
as the lungs are consolidated, air cells blocked 
up, or the lung capable of ready inflation. Dif- 
ferences in this respect will grade the nature of 
disease. 

Friction sounds show pleuritic attachments. 
Whenever the pulmonary sounds become flatter, 
or are altogether superseded, or where they ac- 
quire increased sonorousness or clearness, you 
may rely upon it, there is diseased structure. 

We give a table for reference. It will be a 
good guide in medical examinations in the several 
important points at issue. 



35 



TABLE INDICATING DISEASE OF LUNGS. 



Mucous rattle. 

Submucous. 
Cavernous. 



RELATIVE TO INSPIRA- 
TION AND EXPIRATION. 

Coexisting with 
both. 

Predominating in 

inspiration. 
Coexisting with 

both acts. 



Humid crackling. More distinct in 
inspiration. 

Dry crackling. Exclusively in in- 

spiration. 

Crepitation or Rhon- Coexisting in inspi- 
chus. ration. 

Secondary Crepita- Coexisting in both, 
tion. 

Sonorous rattles. Inspiration and ex- 

piration. 

Friction sounds. In both acts. 



DISEASE ASSOCIATED 
WITH. 

Bronchitis after se- 
cretion has been 
established. 

Capillary Bronchi- 
tis. 

Vomica in Phthi- 
sis. Dilatation 
of Bronchitis. 

Softening in tuber- 
cles. 

Softening. 

Pneumonia. 
Pneumonia. 
Bronchitis. 
Pleurisy. 



Sounds in health, in all cases, should corre- 
spond on both sides. Variations in either are 
suspicious. Placing each in juxtaposition, the 
medical examiner has a ready method of detec- 
tion, as cases correspond with the above stan- 
dard of disease, and should, in connection with 
the vital signs as revealed by sputa, &c, have 
no difficulty in giving a decided opinion. 



36 

Question 5 of examination, and 12 of applica- 
tion. Did the applicant spit blood ? A common 
error has crept into companies to totally discard 
u blood-spitters," " ipso facto /" and hasty judg- 
ments have been formed as to the evidence of 
Phthisis on this ground alone. We should, in 
such cases, ascertain the facts in each individual 
case. A true hemorrhage is the raising of blood 
only. In Pneumonia we have " rusty colored 
sputa." The applicant, ignorant of the distinc- 
tion, frequently calls this spitting of blood, and 
fatally prejudices his case. The medical exa- 
miner should inquire how the blood was ejected? 
Whether by act of vomiting? Whether by 
hawking? Whether slowly or rapidly? The 
color, odor, and taste ? Each one is an index 
of paramount importance towards forming a 
rational opinion. When the patient's form, 
general appearance, slight frame, and short dry 
cough, indicate a debilitated constitution, and 
there have been predispositions to hemorrhage 
in early life, either b} r bleeding from the nose, or 
slight ejections of blood from the throat sponta- 
neously, we may well fear such an history. In 
such cases the examination should be very mi- 
nute; and when the applicant is under 35, with 



SI 

a scrofulous diathesis, it will be good policy to 
reject him. 

In a case of an applicant, the following answer 
was elicited to the question, Did you spit blood? 
He replied, " Yes, about two years ago.' 7 "How 
much ? 77 " About a teaspoonful. 77 The applica- 
tion went to the home office for approval, when 
the cautious president declined it with these 
words : " Before we take ' blood spitters, 7 we 
wish a more minute history of their case. 77 The 
company rejected. Hence, in this point it is im- 
perative that examiners should enter fully into 
the details in the case. 

Pathologists differ in the pathognomonic signs 
of hemorrhage. Some assert, as Louis, that in 
all cases we must suspect tubercles. Rokitansky 
says, " Tuberculized growths appear to be pecu- 
liarly liable to inflammation ; tubercle being wont 
to set up reactive processes of inflammation 
everywhere in its circumference. In this way 
the hemorrhagic inflammatory process often con- 
curs with local tuberculosis without depending 
upon tuberculous crasis. That tuberculosis acts 
as a source of hemorrhagic effusion is rendered 
probable by experience, but it is by no means 
proved,'' 7 

Mons. Andral says: "More than one-fifth of 
4 



38 

the cases of haemoptysis are not tuberculous ; 
that is, are riot dependent on or associated with 
tubercles." Dr. Ware, in 386 cases, reports 62 
recovered. These lived in ordinary health, and 
died of disease having no connection with the 
existence of tubercles. The length of time dur- 
ing which immunity occurred varied from two 
to thirty-seven } r ears. " These facts," says. he, 
u show that neither the existence of tuberculosis 
nor a strong proclivity thereto, is to be positively 
predicated in pulmonary hemorrhage." 

George B. Wood, M. D., says : " Though un- 
able to produce statistics upon this point, I am 
disposed to believe, as the result of observation, 
that independently of menstrual derangement, 
more cases of hemorrhage from the lungs occur 
without tubercles than with." 

Bleeding from the lungs is relatively in some 
cases conservative, as in vicarious discharges. 
Here they assume other channels, until nature 
resumes its first order. Then, again, there are 
hyperaemic and anaemic conditions of the. system, 
in which we have such symptomatic develop- 
ments. It is for the examiner to say how much 
they invalidate the risk offered. 

Taking these views " pro and con," the medi- 
cal examiner is to bring to bear every available 



39 

resource. Measurement, expansion and inflation, 
whether applicant has lost or is losing flesh? 
Cough, if any ? Expectoration, if any ? Periods 
of, if any ? Yocal resonance ? Character of 
sounds in different regions — Pain in chest, if 
any ? Frequency — intervals between ? Age of 
occurrence ? General physique ? Each and all 
of these will lead the examiner to a ready and 
safe conclusion. While he may not find all of 
these pathognomonic signs, it will be incipient 
and lead him to lay bare u some seeds" of disease, 
at any moment ready for development, and in 
no case should he accept the risk where the least 
suspicion exists of hereditary taint or "implied 
tubercles." 

In the same category comes bleeding from the 
nose, stomach, pulmonary apoplexy, &c. 

The medical man mnst judge in how far these 
will impair the character of the risk offered. A 
medical examination is a study of cause and ef- 
fect, balancing each, with the additional lights 
furnished by science and whatever elevates to a 
healthy standard or depresses below. 

Questions T and 8 of certificate read thus : — 

Has the party ever suffered from palpitation, 
fluttering pain, or other inconvenience in region 
of heart? Rate and general character of the 



40 

pulse. Are the rhythm and impulse of the heart 
health}- ? 

To the medical man with enlarged views as to 
his duty, these interrogatories involve more than 
mere examination of heart's action. They incor- 
porate the whole circulating and blood-making 
system ; lymphatics, lacteals, veins, arteries, pro- 
cesses of chymifieation,chylifieation, and charac- 
ter of blood itself, for all these are blended in the 
heart as an organ. A knowledge of these and 
the great sympathetic ganglia controlling the 
functions of these organs, will enable the physi- 
cian to distinguish between health and disease. 

Percussion will define location of organ ; it 
should be " obliquely in chest, the base being di- 
rected upwards and backwards or towards the 
right shoulder, and the apex forwards and to the 
left, pointing to the space between the fifth and 
sixth ribs," two or three inches to the left of the 
sternum. The shock communicated to the finger 
or hand applied to the surface or heard by the 
ear, is what is termed the " impulse" of the heart. 
" Rhythm" is applied to motions of heart and the 
several sounds in dilatation and contraction. 
Writers give us the following ratio of proportions 
as to time, dividing the sounds into u fifths:" 
First sound, 2-5th; second, 1-5 th; interval, 2-5 th. 



41 

In health, the time occupied by whole should 
correspond with time occupied between one stroke 
of pulse and another. Healthy persons in ex- 
amination present clear and smooth sounds, as 
placid and undisturbed as the breathings of an 
infant asleep. The sound heard is none other 
than normal action of heart in its blood-supply- 
ing process. But when there is a heaving, bel- 
lows sound, we have indications of disease ; and 
these sounds vary in proportion as incipient or 
advanced. 

The healthy sounds of the heart have defined 
limits ; we look for them over the precordial re- 
gion. Sounds out of these limits indicate en- 
largement, and will be accompanied b} r other 
morbid evidences in the veins and arteries sup- 
plying the organ of circulation. Morbid sounds 
are styled " Murmurs" or " Bruits ;" they assume 
names to characterize the distinctive relations of 
each. We have the Bruit de Soufflet, " bellows 
sound." " Bruit de Rape," "rasping sound," 
^BrAnt" or musical sound, and friction sounds 
or "pericardial;/- each is endocardial or exo- 
cardial," as the substance or contiguous parts to 
the heart are concerned. Some writers give us 
eight varieties of sound not heard in health, 
4* 



42 

owing either to constriction or dilatation of the 
organs or vessels furnishing the blood. 

The forms of regurgitation by thickened 
valves, as seen, and felt in the thrill in the arte- 
ries, are all causes which should lead the physi- 
cian to suspect disease, and act accordingly. 
This shows the necessity of following up the 
course of arterial and venous system, when the 
valves of the organ are in anywise roughened 
and give the peculiar " Bruit" showing contrac- 
tions in their orifices. 

Dyspnoea, pain, and the color of the individual 
are not to be overlooked. The bulging of the 
eyeballs and livid character of the tongue — and 
in adults advanced in life, the arcus senilis — 
must be heeded as guides where other sounds 
of the heart and diagnostal symptoms fail in 
producing evidences as to the organ's normal 
condition. 

It must be borne in mind that these sounds of 
the heart existing, they are not in themselves 
sufficient evidence that the risk is not a ggod 
one ; they are often present, and yet may be 
simply functional, owing to disturbances of the 
great sympathetic ganglia which reach out and 
operate on the whole processes of assimilation in 
the human economy. This is illustrated by 



43 

effects of fright, fear, sudden emotion of any 
kind upon the circulation. Palpitation, syncope, 
and sudden death follow, without any material 
or abnormal condition of the central organ of 
the bloodvessel system. When the medical 
examiner is led to believe that " murmurs" 
heard have little relation to organic disease and 
are functional in character, he should ask the 
time of day in which these apparently morbid 
conditions are most manifest ; whether before 
or after meals ; whether there be any difference, 
whether after a hearty meal or when abstemious ; 
the personal habits of the individual, if he have 
any vices, &c. &c. 

If, after the light thrown upon this condition, 
there be any amelioration, it is the duty of the 
physician to give the doubt in favor of the ex- 
amined, and accept ; if he hesitates, to postpone 
for re-examination, and not summarily reject. 
The examined has rights, and his case should not 
be prejudiced by too much haste, even though 
sounds differing somewhat from health should be 
heard. Simulated cardiac troubles are often 
caused by engorgement of viscera and blood- 
vessel or blood-forming system. 

We have adverted to anemia and hyperemia ; 
these come under the same category ! The se- 



44 

quelaof scarlatina, measles, diphtheria, resulting 
in albuminuria and cardiac accumulations, should 
be inquired into. Rheumatism and gout, with 
neuralgia of heart, should there have been these in 
family record, are causes for a rigid examination. 
Great circumspection is necessary on these points, 
not only in regional examination of the heart, 
but general examination of urine and the general 
secretory organs concerned. 

It will not be necessary to direct the medical 
examiner as to character and kinds of pulse, only 
to say that too much reliance on the pulse is fal- 
lacious. While a pulse too slow or too rapid 
may be cause to hesitate, there are personal 
idiosyncrasies where these exist, and yet the 
heart is perfectly healthy. 

The tongue, pulse, and general appearance of 
patient are only guides. The medical man's 
knowledge must carry him through " cause and 
effect," and after each has been studied, he can 
then alone render a true opinion. 

Question 9 — Has the party had any disease of 
the liver or kidneys, dyspepsia, colic, dysentery^ 
hernia, strangury, or other disease of the abdo- 
minal viscera ? If so, state particulars. 

Question 10 — Has the party had scrofula, 
rheumatism, gout, dropsy, or other disease not 



45 

enumerated, or an} 7 mechanical injury? If so, 

state particulars. 

The medical man's attention in the first series 
of questions is directed particularly to the viscera 
— to functional derangements, inflammatory and 
mechanical. It is for him to say whether the 
dyspeptic is so far gone as to be precluded, or 
whether he will by care pass through the allotted 
time of life. Physicians well know that despon- 
dency in this disease is much the greater evil ; 
and a proper course of regimen and diet will 
carry the applicant along to his expectation, all 
things being equal. 

Should he have jaundice, or his liver, spleen, 
and kidneys suffer from frequent attacks of inter- 
mittent ; or being of a bilious temperament, the 
liver, the weak organ of the system, it were well 
to make a note of the same, and submit all par- 
ticulars to the company for final decision. 

In all suspected diseases of the liver, the appli- 
cant should be examined in the recumbent posi- 
tion, with the limbs drawn up. Pressure in 
region of liver will detect the least evidence of 
disease. Dropsy originating from disease of the 
liver, independent of the heart — a distinction may 
be entered in this case, and should be submitted 
to the company for determination and fuller in- 



46 

structions. The applicant should not be cut off 

altogether. 

Scrofula, rheumatism, and gout have already 
been mentioned. Where rheumatism has seri- 
ously impaired the heart, and it is acute in 
character, there is no necessity of progressing in 
an examination. Where it is muscular, as in 
" pleurodynia," and may be occasioned b}^ sudden 
exposure, and disappears without leaving a trace 
behind (as often occurs), in such cases it would 
be perfectly legitimate to accept the risk. 

Diseases of the kidneys — in diabetes, for in- 
stance — no prudent man should hesitate for a 
moment. Where evidences exist in the urine, 
and calculi are passed in micturition, with a 
gout}' diathesis, also reject. Some persons are 
apt to be loose in their terms, and style the least 
deviation from nature in the urinary organs 
" disease' 7 — viz., a suspension of urine or " pain 
in the kidneys." This is misleading the exami- 
ner, as he well knows certain kinds of food may 
produce these consequences, and traces be seen 
in the urine itself, without impairing the organ 
or showing any inflammatory or disintegrating 
action in the secreting power of the kidneys. 

Hernia is a serious trouble, owing to incarcera- 
tion and its consequences. Here the medical 



47 

examiner should be cautious. On all occasions 
where the bowel is reducible, a well adjusted 
truss should be ordered ; and the policy should 
hove a restriction, in which the risk would only 
hold good, this precaution being folloived out. A 
mere direction of the phj-sician in the case is a 
"nullity," policies in such cases should be" spe- 
cial," aside from all others. 

In diseases not enumerated, we would advert 
to " fistula in ano." Where this exists, the 
patient's whole system should be thoroughly 
canvassed. Hereditary taints will often show 
themselves in family history. If, however, the 
physical organization be good, no cough or 
appearance of tubercles in a rigid examination, 
no decrease of weight and no inconvenience, the 
discharge operating as a " conservative," the case 
should be submitted to the company for further 
investigation. On no account should the medi- 
cal examiner be hasty in his conclusions, none 
of the indices of dyscrasia existing. 

Asthma and emphysema are special subjects 
for " home office," especially the former; when 
localit3 T , occupation, &c, may be ameliorating 
circumstances, guiding the decision of the offi- 
cers. 



48 

Haemorrhoids, whether bleeding or no, and 
the injuries to the constitution or the reparative 
effects of same, require careful scrutin} 7 on the 
part of examiner. Prolapsus of rectum, indicat- 
ing a deficient nervous power, is cause for rejec- 
tion. Stricture of the bowels and urethra, en- 
largement of prostate gland, diseases which 
may exist for years, but which are aggravated 
by inflammations at any moment, putting in 
jeopardy the life of applicant, should be cause 
for rejection. 

Frequent attacks of diarrhoea, or dysentery 
and colic, should place the examiner on the 
alert, and make him cautious in his acceptance 
of such risks. Rejection, even though the appli- 
cant appear sound, would be better policy than 
acceptance. 

This brings us to a conclusion of the questions 
on application. We have reviewed the points 
at issue, and believe have succeeded in ac- 
cording to the medical examiner a very import- 
ant position among insurance officers. Is he 
fairly compensated for his weighty responsi- 
bility? He is subject to numberless inconveni- 
ences ; and we submit to companies whether the 
present method of remuneration is not too nar- 
row, and the method fraught with danger to the 



49 

companies represented. Would it not be better 
to impress upon him his great importance and 
responsibility, and elevate him in the interests 
of the company, to a standard equal with the 
financial managers ? 

We here add, as in place, the following from 
an address issued by a certain well-known com- 
pany :— 

" Information as to the health of the individual 
can only be obtained from the insured. He is 
asked certain questions. Upon his answers the 
companies base their action. The} 7 ask what 
their experience and knowledge have taught 
them is material. The insured is always speci- 
ally notified that upon the absolute truth of his 
answers depends the validity of his policy. Upon 
this basis the contract is made. If the answers 
are untrue, the basis of the company's calcula- 
tions fails. The proportion of deaths in a given 
time is greater than was expected ; the company 
cannot pay its losses, and insolvency and ruin 
are the result. Who suffers the loss ? Not the 
officers, for the}" have their salary ; not the stock- 
holders, for there are none, the company being 
mutual ; but the policy holders who have told 
the truth in their applications must suffer.' 7 

In an every-day practice to have but an hour 
5 



50 

to spare at an insurance office, and be expected 
to pass on the merits of half a dozen or more 
cases, when, as will be perceived, to do his duty 
and review one case might require as man} 7 
hours, is it a wonder that so many cases are 
passed as coming up to expectation, that die 
years before the time, especially when the merits 
of the case have to be so summarily dealt with? 
We submit it to these institutions whether a re- 
form in this quarter is not as essential as an ac- 
tuarial calculation on prospects of longevity and 
means to enhance the interests of companies in 
computing new tables and rates. It is all well 
that companies should be prudently managed ; 
no one of the insured will find fault with that. 
Yet it is to the interest of every company that 
their medical examiner should be chosen "from 
among the best of men," and paid in proportion 
to his responsibility. 

The medical man stands between the insured 
and the company. Shall he be able to sift a case 
as hurriedly as we have shown, should be the 
case in large offices, where we have it advertised 
" The medical man stays but one hour per clay." 
The whole thing bears absurdity in its face, and 
needs a thorough reformation. 



51 

Another question material in every examina- 
tion is " identity.' ' Every company should de- 
mand a photograph of the insured. In the case 
lately decided in court, how easily a substitution 
could have been effected ! The resemblance to 
the individual would have been a check, and 
brought to mind to the examiner the substitute 
and the original. A case recently occurred in 
one of our western cities where a deception was 
practised upon companies involving $30,000. 

Each examination should be strictly confiden- 
tial, and only between the company and the 
examiner himself, exclusively of the agent fur- 
nishing the risk. There should be no knowledge 
as to result of examination until the decision is 
reached from the office. 

We have now brought our labors to a close. 
If in the course of this work we have been useful 
in guiding companies to a more rigid inquiry into 
the character of its examiners, we have suc- 
ceeded. We know skilful medical men need no 
invitation to more scrutiny in their cases, yet we 
cannot see how, under the circumstances, it can 
be expected from them, with their time otherwise 
occupied in professional duties, that they can 
always give a wise conclusion. Let the medical 
man be sustained, as he richly deserves, and the 



52 

longevity of the risks will be proportional^ 
increased. If, however, companies will pursue a 
narrow course, it is for the applicant to choose 
between those who are, and those who are not, 
" penny wise and pound foolish." 



